Three decades of research in the United States indicates that elderly Americans who are dying often spend their final days in pain and receiving treatments they would not choose. One in four deaths among older adults occur in or shortly after discharge from an intensive care unit, where there are well-documented problems with clinician-family communication and end-of-life care. These deficiencies are associated with high rates of adverse bereavement outcomes among family members, poorly informed treatment decisions, and high utilization of expensive, burdensome treatments at the end of life. Unfortunately, there are no practical, generalizable interventions proven effective in mitigating these three public health problems. In a study funded by the NIA (Beeson K23AG032875), we developed, refined, and successfully pilot tested the Four Supports Intervention, a multifaceted intervention in which a specially trained nurse intensively provides four types of support to surrogates in coordination with the clinical team: emotional support, communication support, decision support, and anticipatory grief support. The objective of this proposal is to conduct a multi- center efficacy trial of the Four Supports Intervention among 400 critically ill older adult. The central hypothesis is that by intensively supporting surrogates in this highly stressful circumstance, the Four Supports Intervention will improve key elements of decision making, decrease long-term psychological distress among surrogates, and achieve more patient-centered care near the end of life. In Aim 1, we will use validated instruments to assess the intervention's impact on key elements of decision quality and the patient- centeredness of care decisions. In Aim 2, we will assess the intervention's impact on surrogates' symptoms of anxiety, depression, PTSD, and complicated grief over 6 months of follow-up. In Aim 3, we will conduct an economic evaluation of the intervention to determine the costs per patient of implementation, as well as the impact on health care costs during the index hospitalization and over 6 months of follow up. The research will have high impact if successful because it will yield a pragmatic solution to important public health problems that potentially affect more than 500,000 older adults who die annually in ICUs. The intervention is innovative in its theoretical grounding in decision psychology, the breadth and intensity of support provided to surrogates, and the strategy of training a nurse selected from the hospital's existing staff to deploy the intervention, rather than using specialized professionals who may not be widely available in U.S. hospitals. The work is feasible in our hands because our team of established investigators developed and successfully pilot-tested the intervention, and because we have a proven record of successfully conducting multi-center studies of surrogate decision making in ICUs.